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An older adult diagnosed with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse?
- A. Dementia
- B. Living in a rural area
- C. Being part of a busy family
- D. Being home only in the evening
Correct Answer: A
Rationale: Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.
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A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, 'Why are you such a stupid kid?' The wife says, 'I have difficulty disciplining the children. It's so frustrating.' Which comments by the nurse will facilitate the interview with these parents? (Select all that apply.)
- A. Tell me how you punish your children.
- B. How do you stop your baby from crying?
- C. Caring for four small children must be difficult.
- D. Do you or your husband ever beat the children?
- E. Calling children 'stupid' injures their self-esteem.
Correct Answer: A,B,C
Rationale: An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by 'yes' or 'no.'
A patient tells the nurse, 'My husband is abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me.' What risk factor was most predictive for the husband to become abusive?
- A. History of family violence
- B. Loss of employment
- C. Abuse of alcohol
- D. Poverty
Correct Answer: A
Rationale: An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.
An 11-year-old child says, 'My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn.' Which nursing diagnosis applies to this child?
- A. Chronic low self-esteem, related to negative feedback from parents
- B. Deficient knowledge, related to interpersonal skills with parents
- C. Disturbed personal identity, related to negative self-evaluation
- D. Complicated grieving, related to poor academic performance
Correct Answer: A
Rationale: The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.
An older adult, diagnosed with Alzheimer's disease, lives with family and has multiple bruises. The home health nurse talks with the older adult's daughter, who becomes defensive and says, 'My mother often wanders at night. Last night she fell down the stairs.' Which nursing diagnosis has priority?
- A. Risk for injury, related to cognitive impairment and lack of caregiver supervision
- B. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation
- C. Impaired verbal communication, related to brain impairment as evidenced by the confusion
- D. Insomnia, related to cognitive impairment as evidenced by wandering at night
Correct Answer: A
Rationale: The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of impaired verbal communication or noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis risk for injury is a higher priority.
An adult tells the nurse, 'My partner abuses me only when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it.' Which phase in the cycle of violence prevents the patient from leaving?
- A. Tension building
- B. Acute battering
- C. Honeymoon
- D. Recovery
Correct Answer: C
Rationale: The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.